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levels on serial measurement or an increase of less than 66% in 48 hours suggests
a nonviable fetus.
Septic abortion may complicate an intrauterine infection from a spontaneous
abortion or from an induced abortion. The patient may have signs of fever, severe
pelvic pain, and leukocytosis. Retained products of conception may still be
present and will require surgical evacuation. Broad-spectrum parenteral
antibiotics should be initiated to cover for gram-positive and gram-negative
bacteria. Infections may also occur from polymicrobial organisms, anaerobic
bacteria, and fungi. Consultation with a specialist is imperative.

Bleeding During an Ectopic Pregnancy
An ectopic pregnancy is a pregnancy that is not intrauterine. Nearly all ectopic
pregnancies occur in the fallopian tubes. Adolescents who have had pelvic
inflammatory disease, tubal surgeries, or previous ectopic pregnancies are at risk
of having ectopic pregnancy, though many patients with ectopic pregnancy will
present with no risk factors. Sharp pain, lateralized pain, and pain of moderate to
severe intensity favor ectopic pregnancy. Examination findings that favor ectopic
pregnancy include cervical motion tenderness, lateral pelvic tenderness, and signs
of peritoneal irritation. β-hCG levels may be low compared to an intrauterine
pregnancy of the same gestational age. If an intrauterine pregnancy is not seen on
ultrasound, a transvaginal ultrasound should be performed to look for an ectopic
pregnancy. Sonographic signs suggestive of ectopic pregnancy include a solid or
complex adnexal mass, a pelvic mass, particulate fluid in the fallopian tube, an
endometrial pseudogestational sac, and cul-de-sac fluid that is either moderate to
large in volume or echogenic. Ultrasound and serial β-hCG testing are the main
diagnostic studies for ectopic pregnancy, though in rare circumstances obtaining a
serum progesterone concentration may be helpful; serum progesterone levels are
usually higher in intrauterine pregnancies than in ectopic and nonviable
pregnancies. If an ectopic pregnancy is diagnosed, an obstetrician/gynecologist or
other appropriate surgical service should be called to manage the patient. The
mainstay of treatment is surgery, though early ectopic pregnancies may be

managed medically with the administration of methotrexate. Patients who present
with ruptured ectopic pregnancy must be monitored closely for signs of
hemodynamic instability, sepsis, and shock in the hospital.

Bleeding During Late Pregnancy
If the patient is 20 weeks pregnant or more by history or abdominal examination,
potential causes of bleeding that must be identified urgently are placenta previa
(placenta close to or overlying cervical os), abruptio placentae (premature


separation of the placenta), uterine rupture, and vasa previa (fetal vessels
traversing closely to cervical os). An obstetrician should be consulted at the
earliest opportunity regarding further ED management of the pregnant patient
with second- or third-trimester bleeding.
Digital vaginal examination in a female in late pregnancy presenting with
vaginal bleeding should initially be avoided because uncontrollable hemorrhage
may be provoked in a patient with placenta previa. Vital signs, physical
examination, and laboratory studies should be obtained to evaluate for
hemodynamic instability. A transabdominal ultrasound should be performed to
assess for the location of the placenta. A transvaginal ultrasound may also need to
be performed to better visualize the placenta location in relation to the cervical os.
The fetal heart rate should be monitored, and a large-bore intravenous catheter
should be inserted. Initial laboratory evaluation should include determinations of
the blood type and antibody screen, hematocrit, platelet count, fibrinogen level,
and coagulation studies to screen for disseminated intravascular coagulation,
which may be present in moderate and severe abruption.

Bleeding With Shock
If the patient with vaginal bleeding is in the first or early second trimester of
pregnancy and has shock or early signs of cardiovascular instability (pallor,

perspiration, vomiting), ruptured ectopic pregnancy or septic abortion must be
ruled out. Because of the urgency of the situation, treatment of shock and
diagnostic measures should be undertaken simultaneously. Pelvic examination is
performed and obstetric consultation should be obtained rapidly. Emergency
surgery may be necessary for critically ill patients with ectopic pregnancy. Fluid
resuscitation and antibiotics should be administered for patients with suspected
septic abortion.
If the patient is ≥20 weeks of gestation, hypovolemic shock should be
suspected from placenta previa, abruption placenta, uterine rupture, or vasa
previa. Appropriate measures should be taken to provide volume resuscitation,
and obstetrics must evaluate urgently.
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